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Home , Neonatal jaundice, Polycythemia

Journal of Kurdistan Board of Medical Specialties (2018) Vol. 4, No.1 Neonatal , Presentations and Associations: A Case Control Study Dlair Abdulkhaliq Chalabi*, Kawes Omer Zangana ** * Assistant professor, Hawler Medical University, College of Medicine, Pediatric Department ** Assistant professor, Hawler Medical University, College of Medicine, Pediatric Department Corresponding author: Dr. Kawes Omer Zangana. Email: [email protected]

Abstract Background and objectives: Neonatal polycythemia is characterized by a venous more than 65%. Inci- dence of neonatal polycythemia ranges from 0.4-5%, most affected have no clinical signs. Neonates may present by acrocyanosis, plethoric، , respiratory distress, poor feeding or apnea. The aim of the study was to find out the prevalence of neonatal polycythemia, identify the risks and recognize most important clinical presenta- tions. Methods: A case-control study conducted at the maternity hospital in Erbil city from 1st February 2013 to 1st May 2013. The study enrolled 500 neonates, among those neonates fifty-three of them revealed central polycythemia. The newborns were considered to be polycythemic if the venous hematocrit was greater than 65%. Results: In this study, 53(11.85%) cases were polycythemic, 30 cases were male 36 (67.9%) with male: female ratio was 2.1:1. Poly- cythemic of less than 2 hours of age were 25 (47.2%) cases, 10 cases (18.9%) were premature. APGAR score in the first minute was less than three in 15 cases (28.3%) and this was statistically significant. Plethora was seen in seven cases, 5 (62.5%) cases in group one and 2 (15.6%) cases in group two. Severity of polycythemia was significantly related to maternal hematocrit. Conclusions: Males were affected more than females. was the main pres- entation followed by plethora, irritability, respiratory distress and poor feeding. Keywords: Polycythemia; Hematocrit; Neonates.

Introduction the newborn2,4. Neurologic symptoms (e.g., irritability, ab- Neonatal polycythemia is characterized by a venous he- normal cry, jitteriness, poor feeding, lethargy, , matocrit that greatly exceeds normal values for gestational and apnea) occur in approximately 60 percent of affected and postnatal age1. The most widely accepted definition is patients 10-12. The cause of these symptoms is uncertain a venous hematocrit of more than 65%2. A newborn is also but may be related to metabolic disorders associated with regarded as polycythemic if capillary hematocrit is 70% or polycythemia or to reduced cerebral flow. Gastro- greater. Hematocrit at term will rise from levels intestinal symptoms, which occur in as many as 20 per- to a peak at 2 hours of age and then drop slowly over the cent of affected patients, include abdominal distention next 12 to 18 hours3. and poor feeding, although the latter is sometimes due to The incidence of neonatal polycythemia ranges from central nervous system abnormalities12. Necrotizing enter- 0.4-5% of total newborn populations4-6. Polycythemia of ocolitis is sometimes associated. is a com- the newborns may be the consequence of compensato- mon metabolic problem in affected patients. It occurs in ry mechanism for intrauterine , as well as it may 14 to 40 percent of cases12, 14. At least one-third of infants occur secondary to fetal transfusions or have fetal origin. with polycythemia develop hyperbilirubinemia3. Thrombo- Polycythemia secondary to fetal transfusions may occur cytopenia occurs in some infants with polycythemia15. The due to delayed cord clamping after birth, acute fetal dis- aim of the study was to find out the prevalence of neonatal tress, -to-twin transfusion syndrome, maternal- fetal polycythemia, identify the risk and to recognize the most transfusion, , holding the baby below important clinical presentations the level of introitus7- 9. Most affected infants have no clinical signs of the condi- Patients and Methods tion10. Symptoms, when present, often begin by two hours This is a case-control study, conducted at Erbil in mater- after birth, after fluid shifts have occurred and the hema- nity hospital, capital city of Kurdistan region.. The samples tocrit is highest, onset may be delayed to the second or have been taken from the newborns babies regardless of third day11. the mode of delivery from 1st February 2013 to 1st May Cardiorespiratory signs such as acrocyanosis and sluggish 2013. peripheral perfusion are common; affecting 67 percent of The study enrolled 500 neonates irrespective of the ges- patients in one study, infants with polycythemia may ap- tational age and . Among these 500 neonates pear plethoric. Cyanosis occurs in as many as 17 percent ninety-nine of them had peripheral polycythemia which 12, 13. Respiratory symptoms, including tachypnea and dis- undergone central venus sampling from antecubital area tress, develop in 10 to 15 percent of patients 12. Infants to confirm polycythemia and to exclude local causes, fif- with polycythemia may develop heart murmurs, heart ty-three of them revealed central polycythemia. One hun- failure, and increased pulmonary vascular resistance, dred forty cases taken as control in this study, they includ- which may lead to persistent pulmonary of ed neonates delivered in the same place without clinical

68 Kurdistan Board of Medical Specialties Journal of Kurdistan Board of Medical Specialties (2018) vol.4, No.1

or laboratory findings of polycythemia and were clear from el of mother’s introitus and newborn of mothers who had any neonatal problems. Gestational age determined from received blood before delivery. Written and oral consent mother’s menstrual history and confirmed by modified was taken from all mothers guardians. Chi square test of Ballard’s scoring. Small for gestational age (SGA) is a birth association was used to compare between proportions weight that is below the 10th percentile for gestational age and when the expected count of > 20% of the cells of the and large for gestational age (LGA) is birth weight above table was <5 fishers exact test was used. Independent t 90th percentile for gestational age16. refers test used to compare between means. A p value of ≤ 0.05 to a birth that occurs at or before 37 weeks of gestation, was considered significant. a term birth is defined as a birth occurring between 38 and 42 weeks, and a post-term birth is defined as a birth Results occurring after 42 week17. Apgar score was taken for each Among the 500 newborns, 53(11.85%) were polycythemic delivered neonate in both groups in first and fifth minutes and 447 were non-polycythemic. From 53 polycythemic and documented in each case sheet of delivered neonate. neonates, 30 cases were male 36 (67.9%) and 17 (32.1%) Growth parameters including weight, length and occip- cases were female, with male: female ratio equal to 2.1:1, itofrontal circumference had been taken using scale for while in the control group, 79 (56.4%) cases were male measuring weight and tape measure for measuring length and 61 (43.6%) cases were female, being male gender and occipitofrontal circumference. Capillary hematocrit increases the risk of polycythemia by (0.6) times but this determined on blood samples obtained by pricking the ne- factor was statistically not significant. Age of neonates less onate’s pre warmed heel with med point blood lancet in than 2 hours that showed center polycythemia were 25 the first twelve hours of life. All capillary were (47.2%) cases while those showed to be polycythemic af- determined in duplicate in 17 mm long and 1 mm wide ter 2 hours of age were 28 (52.8%) cases, the values were (internal diameter) capillary tubes spun at 10,000 RPM for not significant statistically p value 0.59 but OR was 0.82. 5 minutes, in a micro hematocrit centrifuge (H-1200F) and Regarding gestational age; 10 (18.9%) cases of premature the hematocrit read using a reading device (REMI read- neonates showed to be polycythemic while no premature ing device). Plasma separates and the packed cell volume neonates in control group, and this was statistically highly is measured to give the hematocrit. Most of the reported significant with p value <0.001with OR 4.25. Anthropoem- data on polycythemia is on centrifuged hematocrits. In etric measures in both group were significant, number of cases were the capillary hematocrit was 70% or greater, cases that lies below 10th centile in weight among were a central venous sample from antecubital area was tak- 7 (13.2%) cases while in control group were 4 (2.87%) en to confirm polycythemia and to exclude possible local cases, p value was 0.022. Apgar score also showed sig- causes, if the venous hematocrit was greater than 65%. nificant values, Apgar score of less than three in the first Investigations like total serum and blood sugar minute was present in 15(28.3%) cases while in control have been done for all polycythemic babies. Criteria of ex- group score was present in 4(21.1%) cases, p value was clusion were cord milking, Holding the baby below the lev- less than 0.001, as shown in Table 1.

69 Kurdistan Board of Medical Specialties Journal of Kurdistan Board of Medical Specialties (2018) Vol. 4, No.1

Table (1): Comparison between neonate with central polycythemia and control group regarding certain variables of the newborn

Maternal risk factors were pattern of delivery; in which normal vaginal delivery were more in both groups, 30 cases (56.6%) in polycythemic group while 101 (72.1%) in control group which was statistically significant (p value was 0.039). Majority of were single, parity of mothers was also not significant between both groups (p value was 0.24) Significant important factors were clumping after three minutes of delivery on polycythemic group was 29(54.7%) cases while control was 119 (85%), more than three minutes was 24(45.3%) cases, (p value was less than 0.001 and OR was 4.69). Maternal smoking was present in 5(9.4) cases in polycythemic group while no case was reported in control group, (p value was 0.001 and OR 3.91) as shown in Table 2.

Table (2): Comparison between neonate with central polycythemia and control group regarding certain obstetrical var- iabls.

70 Kurdistan Board of Medical Specialties Journal of Kurdistan Board of Medical Specialties (2018) vol.4, No.1 Mean of all anthropometric measures in cases were less when PCV is equal or more than 70 while group two when than control group but all the values were close to each PCV is less than 70. Plethora was seen in seven cases out other and didn’t showed any statistical significance. Mean of 53, 5 (62.5%) cases in group one and 2 (15.6%) cases oxygen saturation in polycythemic group were 95.57(± in group two; (p value was 0.001 and OR was 10.95). Res- 2.8) while in control group was 94.74(± 2.01) the differ- piratory distress also occurred in seven cases, 4 (8.89%) ence between both groups were not significant statisti- cases were in group two and 3 (37.5%) cases in group cally. Significant values were mean maternal Hematocrit one, (p value was also significant.0.027, OR 3.9). (PCV); it was 72.96(± 8.19), it was much higher in com- occurred in one case in group two and no case reported parison to control group 68.16(± 8.05), p value was highly in group one. was present in 5 cases in significant. The mean PCV of the cases were 75.25(3.14) group one and 8 cases in group two, (p value was 0.037 while PCV values in control group was 57.23(5.36) the and OR was 4.6), and other presentations are shown in comparison between both groups was highly significant, Table 5 p value was less than 0.001. All data are shown in Table 3. Table (5): Clinical presentation seen in neonates according Table (3): T test comparison between means of poly- to severity of polycythemia cythemic and control group

According to the severity of polycythemia cases were di- vided into two groups, maternal PCV was higher in group Discussion two 78.65(9.65) in comparison to group one 71.96(±7.59), With regards to neonatal central polycythaemia, this study (p value was 0.033). Mean blood sugar in group one was showed important risk factors including preterm delivery 68.25(mg/dl) (±29.3) while in group two was 50.51(mg / in 18.8%, small for gestational age 13.2%, neonates with dl) (±15.64) (p value was 0.014). Other data are shown in low APGAR scores in one and five minutes (28.3 and 50.7% Table 4 respectively). In a study published by Abbas18, it is found Table (4): Severity of polycythemia in relation to certain that 36% with small for gestational age and 18% devel- variables oped polycythemia. Wexner19 showed that 36% with small for gestational age and 13.8% developed polycythemia. Other studies6 showed incidence of polycythemia in term small for gestational age as 15% compared to 2% of term babies appropriate for gestational age. Another study showed higher risk in preterm neonates, neonates of di- abetic mother (20%), and small for gestational age (28%) 20 as polycythemia may be the consequence of compen- satory mechanism for , perinatal as- phyxia which neonates in these situations are very prone to it7,8, 9,20. Normal vaginal delivery was seen in control group 72.1% in comparison to 56.6% in cases OR was 0.5; this means that normal vaginal delivery decreases the incidence by half fold18. Other data showed neonatal polycythaemia can be reduced by two and half folds14 as vaginal de- *Values in mean (SD) livery has potent uterine contractions that prevents poly- cythemia if clumping not delayed21.In multiple pregnancies Presentations that seen in polycythemic neonates were there’s possibility of fetal to fetal transfusion so increases classified in to two groups according to severity, group one the risk of polycythemia by five folds as shown this study. 71 Kurdistan Board of Medical Specialties Journal of Kurdistan Board of Medical Specialties (2018) Vol. 4, No.1

Risk of polycythemia in multi pregnancies was 11%, other inat Neonatal Nurs. 2003 Jul-Sep;17(3):209-19 studies showed 12% and 15%8,18. 5. Sarkar S, Rosenkrantz TS. Neonatal polycythemia and hyperviscosity. Onset of clumping has a big role in developing poly- Semin Fetal Neonatal Med. 2008 Aug;13(4):248-55 cythemia; as our study showed an increased the risk by 6. Kandasamy J. Polycythemia of the Newborn. 2017.Available from 4.6 folds; this agreed with the fact that delay clumping http://emedicine.medscape.com/article/976319-overview#a0199. increases the risk of polycythemia. Maternal smoking in- 7. Jeevasankar M, Agarwal R, Chawla D. Polycythemia in the newborn. creased risk of polycythemia by 3.9 that it is due to in- Indian J. Pediatr. 2008; 75: 68-72. creasing hypoxia, this finding agreed with8,9,22 which is 8. Rosenkrantz TS, Oh W. Polycythemia and hyperviscosity in the new- explained by the increase in level and in- born. In: De Alarcón P., Werner E. (editors). Neonatal . New creases RBC productions). York, Cambridge University Press, New York , 2005: p.983 As this study showed that difference in mean PCV of the 9.Upadhyay A, Aggarwal R, Deorari AK. Polycythemia in the newborn. polycythemia neonates to control group is highly signifi- Indian J. Pediatr 2002; 69:70-82. cant (P <0.001) and maternal PCV was also highly signif- 10. Mentzer W, Glader B. Erythrocyte disorders in infancy. In: Gleason icant in contrast to control group, as the PCV of the preg- C, Devaskar S (Editors). Avery’s Diseases of the Newborn. Philadelphia, nant mothers highly reflects that of neonates and affects WB Saunders, 2011 9th ed.: p.1080. PCV of neonates proportionally9. 11. Sankar M, Agarwal R, Deorari A, Paul V. Management of poly- Investigations done were blood sugar level, it was signifi- cythemia in neonates. Indian J Pediatr. 2010 Oct;77(10):1117-21 cantly lower in polycythemic group as glucose consump- 12. Alsafadi T, Hashmi S, Youssef H, Suliman A, Abbas H, Albaloushi tion is more in polycythemic neonates, while count M. Polycythemia in neonatal intensive care unit, risk factors, symp- was higher, it reflects more blood transfusion from mother toms, pattern, and management controversy. J Clin Neonatol. 2014 to the baby or from twin to twin or reflects more synthesis Apr;3(2):93-8. due to hypoxia12. 13. Ramamurthy R, Brans Y. Neonatal polycythemia: I. Criteria for diag- Concerning clinical presentations; jaundice 13(26.4%), nosis and treatment. 1981; 68:168. jitteriness 11(20.7%), plethora 7(13.2%) and respiratory 14. Lubetzky R, Ben-Shachar S, Mimouni FB, Dollberg S. Mode of deliv- distress 7(13.2%), the least recorded presentation was ery and neonatal hematocrit Am J Perinatol. 2000;17(3):163-5. convulsion that occurred in one case. Published data 15. Vlug R, Lopriore E, Janssen M, Middeldorp J, Rath M, Smits-Wint- showed occurrence of neonatal jaundice in 58%, lethar- jens V. Thrombocytopenia in neonates with polycythemia: incidence, risk gy in 30%, respiratory distress in 26%, and hypoglycemia factors and clinical outcome.Expert Rev Hematol. 2015 Feb;8(1):123-9 in 26%, while feeding problems, bitterness and cyanosis 16. Lockwood CJ, Waltham MA, Ramin SM. Overview of preterm labor were not recorded21,22. Al Safadi TR et al12 in his study and birth. Up-To-Date. 2013. Available at: http://www.uptodate.com. found jaundice in 33.5%, respiratory distress in 6.6% and Accessed in 16 january 2014. hypoglycemia in 13%of cases, these all data agree on the 17. Krishnan L, Rahim A. Neonatal Polycythemia. Indian J Pediatr 1997; major clinical presentation and the variation in recorded 64:541-6. cases probably due to severity of polycythemia and asso- 18. Abbas S, Fayadh H. Neonatal Polycythemia: Risk Factors, Clinical ciated risk factors. Manifestation and Treatment Applied. The Iraqi Postgrad Medical J 2013;12: 390-5 Conclusions 19. Wexner E. Neonatal polycythemia and hyperviscosity. Clin. Perina- Our study showed that male babies were affected more tol. 1995;22:693. than females. Jaundice was the main presentation fol- 20. Singh S, Narang A , Bhakoo ON . Polycythemia in the newborn, India lowed by plethora, irritability, respiratory distress, poor Pediatr . 1990; 27:349-52 feeding and least presentation was convulsion. According 21. Hajduczenia M, Jaremba O and Szymankiewicz M. Polycythemia of to our study the risk was higher among preterm babies the newborn. Archives of Perinatal Medicine 2010; 16(3):127-33. and when apgar score is three or less in one and 5 min- 22. Al-Alawi E, Jenkins D. Does maternal smoking in- crease the risk of utes, furthermore this study showed higher association of neonatal polycythemia? Ir. Med. J. 2000; 93:175-6. polycythemia with maternal smoking delaying cord clamp- ing more than 3 minutes and multiple ,

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